Healthcare Provider Details

I. General information

NPI: 1720101850
Provider Name (Legal Business Name): TIMOTHY JAMES PROCTOR PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11882 GREENVILLE AVE STE 107
DALLAS TX
75243-3567
US

IV. Provider business mailing address

11882 GREENVILLE AVE STE 107
DALLAS TX
75243-3567
US

V. Phone/Fax

Practice location:
  • Phone: 972-644-8686
  • Fax: 972-644-8688
Mailing address:
  • Phone: 972-644-8686
  • Fax: 972-644-8688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number32021
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: